Notes from the desk of our CEO Kris Mastrangelo

 

Back to Basics with Documentation: Medicare Audit programs are becoming more frequent throughout the country.  Facilities best defense against medical review revenue "take-backs" is continual review and refinement of therapy and nursing skilled documentation.  Harmony has generated the following suggestions for enhancing documentation to support the medical necessity of therapy intervention. Documentation should reflect objectives, goals and evidence of progress or the risks related to lack of therapy intervention. 

• Provide the whole picture of the patient - therapists often know more about the patient than is entered in the record.
• Describe the medical condition of the patient.
• Specify the need for skilled service: For example: safety issues or medical complications.
• Patient reactions should be included in weekly notes.  
   
  Example: Patient required Minimal assist to complete tasks, but pain level is not functional following task completion.  

Or

Extreme fatigue was observed following task completion. 

• A therapist's expectation of progress is very supportive in Medicare documentation.

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